Prsentation PowerPoint

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Radial Access state of the art

• Y. Louvard
• Massy, France

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Transradial approach the best way to reduce the
vascular complication rate and the cost, and to
improve patient comfort
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(No Transcript)
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Impact of Access Site Hematoma With Transfusion
in Patients Undergoing PCI

• 6613 PCI (98-00)(NHLBI) hematoma w transfusion
  1.8 (97 femoral)
• Independent predictors Older age, female,
  thrombotic lesion, 3-VD, renal disease, emergent
  PCI, prior aspirin
• 
  HWT no HWT p
• Procedural death () 10.3
  1.2 lt0.001
• death/MI () 18.1
  3.55 lt0.001
• HWT is a predictor of death/MI (OR 3.49 95
  CI 1.98-6.14)

J. Slater Am J Cardiol 2003 (suppl) 92 18L
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Clinical Significance of Bleeding Complications
From Blankenship Am Heart J 1999 138 S287-S296
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Radial / Femoral Approach meta-analysis Entry
site complications
Agostini P personal communication
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Transradial approach for PCI, for Diagnosis, for
Both?
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ACCESS Study

Radial Brachial Femoral p
Approach failure () 7 4.3
0.3 lt0.001 Procedural success ()
91.7 90.7 90.7 NS Equipment
Guiding cath. (n) 1.3 1.3
1.3 NS Balloons (n)
1.3 1.3 1.3 NS
Stenting () 4.7 7
4.7 NS Procedural time (Min) 4024
3925 3824 NS Fluoro. Time (Min
1311 1210 1110
0.06 Hospital stay (days) 1.52.5
1.83.8 1.84.2 NS
Kiemeneij JACC 1997291269-75
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Radial Artery Diameter (Ultrasound)n120
5f 6f 7f 8f
2,90,6 mm
Y. Louvard unpublished
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Catheters / Devices
/ Technique Compatibility
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A randomized trial of 5 vs. 6 French transradial
percutaneous coronary interventions

• 5 Fr / 6 Fr guiding catheter, 171 pts with
  coronary lesions suitable for 5 Fr transradial
  approach
• 
  5 Fr 6 Fr p
• Procedural success () 95.4
  92.9
• Cor. cannulation failure () 1.1
  4.8 0.08
• Minor hematomas () 1.1
  4.8 0.07
• Loss of radial pulse () 1.1
  5.9 0.05

Dahm JB CCVI 2002 57(2)172-6
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CARAFE (Technical Data)

• Femoral Right Radial Left
  Radial
• N 70
  70 70
• Cross over 0 1 (1.4)
  0
• LCA catheter (n) 1.10.3 1.20.6
  1.10.3
• RCA catheter (n) 1.00.2 1.10.3
  1.00.2
• Total catheters (n) 2.10.4
  1.40.7 2.10.4

pns L Rad , plt.000 vs Femoral and L
Rad
Y. Louvard CCVI 2001 52 181-187
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Looking for the best multipurpose catheter for
Right transradial coronary angiography

• Multipurpose (too much rotation)
• Amplatz AL2 (AL1)
• Champ (dead)
• JL 3.5 (for left and right!)
• Tiger II

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Transradial Approach Reduces Bleeding
Complications and Length of Stay in Patients With
GP IIb/IIIa Inhibitors
FA
RA p value N
2432
164 GPIIbIIIa () 61
90 Major bleeding (n)
164 0 lt0.05 Major
complication (n) 21 0
lt0.05 Minor complication (n)
59 6
lt0.05 Thrombocytopenia (n) 17
3 lt0.05 Length of stay
(hrs) 70.6 36.6
lt0.05
p lt0.05, major bleeding (TIMI criteria), major
(requiring surgical repair), and minor
(pseudoaneurysm or charted hematoma) access site
complications
G. Revtyak Am J Cardiol 2001 88 39G
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Transradial vs. transfemoral approach in primary
stent implantation for patients with acute
myocardial infarction TEMPURA trial

• 149 pts with AMI lt 12 hr, randomized into 2
  groups
• 
  TRI TFI
• N
  77 72
• Cross over (n)
  1 0
• Severe bleeding complication (n) 0
  2
• Success of reperfusion () 96.1
  97.1
• in-hospital MACE () 5.2
  8.3

Saito CCVI 2003 59(1)26-33
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OCTOPLUS Primary endpoint, Intention to treat
analysis
surgery, transfusion, Hb lossgt3g/100ml-Ht
lossgt10, ischemia, FA, vasc. Complic. leading to
discharge delay Large hematoma discharge delay
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Safety of same-day-discharge radial percutaneous
coronary intervention

• 943 Pts same-day discharge radial PCI entry
  site complications or repeat angiogram and/or PCI
  within 24 hours and 1 month ,
• 811 patients responded , 38 patients died, 94
  alive but refused to participate/impossible to
  contact
• 
  24 h 1 month
• Access complication () 2.8
  0
• Chest pain () 2
  11.5
• repeat angio () 0.1
  1.3
• Vessel occlusion () 0
  0.5
• ( lost for FU pts)
  0.2

Ziakas Am Heart J. 2003 146 699-704
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Transradial Approach for non- Coronary Diagnosis
and Intervention ?
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Right Transradial selective vertebral and carotid
angiography
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Transradial carotid bifurcation stenting
J. Théron, Caen, France, personal communication
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Transradial Approach Drawbacks ?It has to be
learned (!)and teached
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Radial approach learning curve in non selected
population
52 69 89
Y. Louvard, preliminary
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Radial approach learning curve in non selected
population
96 97 98
Y. Louvard, preliminary
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Transradial Approach Failure in Relation to Volume

p 0.002
Failure to enter ascending aorta
Y. Louvard, unpublished
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Predictive Factors of Radial Approach Failure

Success Failure p n
2347
53 Age (years)
61.611.3 6511.2
0.03 Male ()
84 73.7
0.068 Hypertension () 42.2
43.4
ns Dyslipidemia () 72.9
69.8 ns Diabetes
() 8.4
13.2 ns Smoking ()
26.9
22.6 ns Left radial ()
3.2 18.9
0.000 Re-radial ()
21.9 17
ns N of Same Radial (n) 1.30.7
1.30.6 ns N Dis. Coro.
Vessels (n) 1.80.8
1.70.7 ns Weight (kg)
76.913.5 72.813.8
0.029 Height (cm)
169.38.3 166.410.3 0.03
Failure to enter ascending aorta
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Radial Approach Failure Rate in Relation to Age

Y. Louvard, unpublished
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Radial Approach Failure Rate in Relation to Weight
Y. Louvard, unpublished
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Predictors of Failure of Transradial Approach for
Coronary Angiography and Interventions
A multivariate analysis of a large series 6,962
TRA (94-98)
Causes of the 475 TRA failures (7) unsuccessful
puncture (69), difficult anatomy (16), brachial
artery spasm (8), unsuccessful canulation (5)
or miscellaneous (2)

G.Barbeau AHA 1999
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Evaluation of a spasmolytic cocktail to prevent
radial artery spasm during coronary procedures

• Automatic pullback device, efficacy of an
  intra-arterial vasodilating cocktail (verapamil 5
  mg, nitroglycerine 200 µg) in reducing radial
  artery spasm
• 
  Cocktail No cocktail p
  value
• N
  50 50
• Pain ()
  14 34
  0.019
• Pain score
  1.7 0.94 2.08 1.07 0.03
• Maximal pullback force (kg) 0.53 0.52
  0.76 0.45 0.013
• MPF gt 1.0 kg ()
  8 22 0.029

Kiemeneij CCVI 2003 58 281-4
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Tortuous Right Subclavian Artery Prevalence and
Predictive Factors

• 2,341 consecutive right radial
  approaches
• Prevalence ()
  10.8
• Cross-over to Left Radial or Femoral ()
  4
• Complications ()
  0
• Independent predictive factors
• OR
  95 CI p
• Hypertension 1.6 1.3-2.1
  lt0.0003
• Age 1.4
  1.2-1.7 0.0001
• BMI 1.2
  1.0-1.4 0.015

Cha CCVI 2002 56 abst 69
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Transradial Approach Drawbacks ?Complications
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A New and Objective Method for Transradial
Approach Screening Comparaison With the Allen's
Test in 1010 Patients

• 1010 pts, 32 female, 19 diabetics, age 62y,
  weight 76 kg, height 1.66 m
• 
  Right Left Right or Left
• MAT lt 9 seconds () 87
  86
• Positive PL Ox () 96
  95
• MAT exclusion ()
  6.3
• PL Ox ()
  1.5

MAT modified Allens test, plethysmography (PL)
and oxymetry (Ox)
Barbeau 2001, 37, 2, Suppl A, 1A-648A
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Early ultrasonic results
270 patients 4 radial occluded (1.3) - 2 with
a negative flow - 2 without flow
J. Monsegu
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Radial Artery/Sheath Diameter Ratio A Predictor
of Severe Radial Artery Flow Reduction
Saïto CCVI 46 173-178, 1999
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IVUS after transradial approach
JACC 2003411109-14
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Use of the radial artery graft after transradial
catheterization is it suitable as a bypass
conduit?

• 67 pts underwent isolated CABG using the radial
  artery (RA)
• 
  preop. transradial no transradial p
  value
• 
  catheterization catheterization
• N
  22 45
• Stenosis-free graft patency
• Left mammary artery () 88
  90 0.87
• Radial artery ()
  77 98
  0.017
• Saphenous vein () 87
  84
  0.42
• Intimal hyperplasia of RA () 68
  39 0.046

Kamiya Ann Thorac Surg. 2003 76(5) 1505-9
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False Aneurysm after PTCA
From P Garot
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Conclusions (1)

• Transradial approach is the best way to reduce
  the vascular complication rate of diagnostic and
  therapeutic coronary (vascular) catheterism less
  expensive, preferred by patients and nurses
• At the price of a slight increase in procedural
  duration and X-Ray exposure for diagnosis only
• It is specially effective in high risk
  populations like old patients, AMI, patients
  treated with powerful anticoagulant or
  antiplatelet drugs

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Conclusions (2)

• Transradial approach allows the use of all
  devices and techniques of modern coronary
  intervention
• Peripheral vascular diagnosis and intervention is
  feasible with the same advantages Subclavian,
  Renal, Mesenteric, Carotid?
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